Endotracheal Tube Malposition Research Articles

Characterization of fatal blunt injuries using postmortem computed tomography.

Rapid triage of blunt agonal trauma patients is necessary to maximize survival, but autopsy is uncommon, slow, and rarely informs resuscitation guidelines. Postmortem computed tomography (PMCT) can serve as an adjunct to autopsy in guiding blunt agonal trauma resuscitation. Retrospective cohort review of trauma decedents who died at or within 1 hour of arrival following blunt trauma and underwent noncontrasted PMCT. Primary outcome was the prevalence of mortal injury defined as potential exsanguination (e.g., cavitary injury, long bone and pelvic fractures), traumatic brain injury, and cervical spine injury. Secondary outcomes were potentially mortal injuries (e.g., pneumothorax) and misplacement airway devices. Patients were grouped by whether arrest occurred prehospital/in-hospital. Univariate analysis was used to identify differences in injury patterns including multiple-trauma injury patterns. Over a 9-year period, 80 decedents were included. Average age was 48.9 ± 21.7 years, 68% male, and an average ISS of 42.3 ± 16.3. The most common mechanism was motor vehicle accidents (67.5%) followed by pedestrian struck (15%). Of all decedents, 62 (77.5%) had traumatic arrest prehospital while 18 (22.5%) arrived with pulse. Between groups there were no significant differences in demographics including ISS. The most common mortal injuries were traumatic brain injury (40%), long bone fractures (25%), moderate/large hemoperitoneum (22.5%), and cervical spine injury (25%). Secondary outcomes included moderate/large pneumothorax (18.8%) and esophageal intubation rate of 5%. There were no significant differences in mortal or potentially mortal injuries, and no differences in multiple-trauma injury patterns. Fatal blunt injury patterns do not vary between prehospital and in-hospital arrest decedents. High rates of pneumothorax and endotracheal tube misplacement should prompt mandatory chest decompression and confirmation of tube placement in all blunt arrest patients. Prognostic and Epidemiological; Level IV.

Predicting the risk of inappropriate depth of endotracheal intubation in pediatric patients using machine learning approaches

Endotracheal tube (ET) misplacement is common in pediatric patients, which can lead to the serious complication. It would be helpful if there is an easy-to-use tool to predict the optimal ET depth considering in each patient’s characteristics. Therefore, we plan to develop a novel machine learning (ML) model to predict the appropriate ET depth in pediatric patients. This study retrospectively collected data from 1436 pediatric patients aged < 7 years who underwent chest x-ray examination in an intubated state. Patient data including age, sex, height weight, the internal diameter (ID) of the ET, and ET depth were collected from electronic medical records and chest x-ray. Among these, 1436 data were divided into training (70%, n = 1007) and testing (30%, n = 429) datasets. The training dataset was used to build the appropriate ET depth estimation model, while the test dataset was used to compare the model performance with the formula-based methods such as age-based method, height-based method and tube-ID method. The rate of inappropriate ET location was significantly lower in our ML model (17.9%) compared to formula-based methods (35.7%, 62.2%, and 46.6%). The relative risk [95% confidence interval, CI] of an inappropriate ET location compared to ML model in the age-based, height-based, and tube ID-based method were 1.99 [1.56–2.52], 3.47 [2.80–4.30], and 2.60 [2.07–3.26], respectively. In addition, compared to ML model, the relative risk of shallow intubation tended to be higher in the age-based method, whereas the risk of the deep or endobronchial intubation tended to be higher in the height-based and the tube ID-based method. The use of our ML model was able to predict optimal ET depth for pediatric patients only with basic patient information and reduce the risk of inappropriate ET placement. It will be helpful to clinicians unfamiliar with pediatric tracheal intubation to determine the appropriate ET depth.

The accuracy of intensive care nurses' interpretation of chest radiographs to recognise misplacement of endotracheal and nasogastric tubes after a single training session and comparison with residents' interpretation

BackgroundMisplacements of endotracheal and nasogastric tubes are frequent encounters in critically ill patients. ObjectivesThe purpose of this study was to assess the effectiveness of a single standardised training session on the ability of intensive care registered nurses (RNs) to recognise the misplacement of endotracheal and nasogastric tubes on bedside chest radiographs of patients in intensive care units (ICUs). MethodsIn eight French ICUs, RNs received a 110-min standardised teaching on the position of endotracheal and nasogastric tubes on chest radiographs. Their knowledge was evaluated within the subsequent weeks. For 20 chest radiographs, each with an endotracheal and nasogastric tube, RNs had to indicate whether each tube was in the proper or incorrect position. Training success was defined as >90% for the lower bound of the 95% confidence interval (95% CI) of the mean correct response rate (CRR). Residents of the participating ICUs underwent the same evaluation (without prior specific training). ResultsIn total, 181 RNs were trained and evaluated and 110 residents were evaluated. The global mean CRR for RNs was 84.6% (95% CI: 83.3–85.9), significantly higher than for residents (81.4% [95% CI: 79.7–83.2]) (P < 0.0001). The mean CRR for RNs and residents was 95.9% (93.9–98.0) and 97.0% (94.7–99.3) for misplaced nasogastric tubes (P = 0.54), 86.8% (85.2–88.5) and 82.6% (79.4–85.7) (P = 0.07) for nasogastric tubes in the correct position, 86.6% (83.8–89.3) and 62.7% (57.9–67.5) for misplaced endotracheal tubes (P < 0.0001), and 79.1% (76.6–81.6) and 84.7% (82.1–87.2) for endotracheal tubes in the correct position (P = 0.01), respectively. ConclusionsThe ability of trained RNs to detect tube misplacement did not reach the predetermined arbitrary level, indicating training success. Their mean CRR was higher than that for residents and was considered satisfactory for detecting misplaced nasogastric tubes. This finding is encouraging but insufficient to ensure patient safety. Transferring responsibility for reading radiographs to detect the misplacement of endotracheal tubes to intensive care RNs will need a more advanced or more in-depth teaching method.

846: IS TRANSTRACHEAL POCUS HELPFUL IN DETERMINING ENDOTRACHEAL TUBE POSITION? A RANDOMIZED CONTROL TRIAL

Introduction: Endotracheal tube (ETT) malposition is associated with adverse events. Chest x-ray (CXR) is the gold standard modality for determining ETT position and depth in the trachea. However, Point-of-Care Ultrasound (POCUS) has emerged as a novel non-invasive alternative. We aimed to determine if an integrated protocol employing both transtracheal ultrasound and CXR for identifying ETT malposition in the trachea, compared to CXR alone, would result in fewer adverse events. Methods: We performed a single-center randomized control trial of intubated patients in a multidisciplinary intensive care unit at an academic hospital. Intubated patients were randomized into two arms: POCUS integrated or CXR alone daily ETT monitoring. In both arms, trained sonographers assessed for ETT position and related adverse events: migration into bronchus, herniation into vocal cords, balloon rupture, unplanned extubation, and aspiration pneumonia. In the POCUS integrated arm, the ICU rounding team was provided with the sonographer’s findings to aid in clinical decision making. A Pearson’s Chi-Squared test was used to compare the results between the two arms. Results: A total of 76 patients amounting to 187 ventilator days were randomized to receive either POCUS integrated (91 ventilator days) or CXR alone (96 ventilator days) daily ETT monitoring. The average patient age was 57.8 years +/- 17.0 years. Most patients were intubated for airway protection (46.1%) and hypoxic respiratory failure (40.8%). There were 10 adverse events recorded (7 aspiration pneumonias, 1 herniation through the vocal cords, 2 migration into a bronchus) out of 187 ventilator days. There was a trend toward lower adverse events in the POCUS integrated group compared to the CXR alone group (2.2% vs. 8.3%; p=0.062, respectively). Furthermore, the ETT depth was adjusted more frequently in the POCUS integrated group compared to the CXR alone group; however, this was not statistically significant (7.7% vs. 3.1%; p=0.165, respectively). Conclusions: Based on our data, the integrated protocol employing transtracheal ultrasound and CXR did not result in fewer adverse events than CXR alone. However, there was a trend toward less adverse events with the integrated protocol, and further investigations with larger sample sizes are needed.

Automated Endotracheal Tube Placement Check Using Semantically Embedded Deep Neural Networks

To develop artificial intelligence (AI) system that assists in checking endotracheal tube (ETT) placement on chest X-rays (CXRs) and evaluate whether it can move into clinical validation as a quality improvement tool. A retrospective data set including 2000 de-identified images from intensive care unit patients was split into 1488 for training and 512 for testing. AI was developed to automatically identify the ETT, trachea, and carina using semantically embedded neural networks that combine a declarative knowledge base with deep neural networks. To check the ETT tip placement, a "safe zone" was computed as the region inside the trachea and 3-7 cm above the carina. Two AI outputs were evaluated: (1) ETT overlay, (2) ETT misplacement alert messages. Clinically relevant performance metrics were compared against prespecified thresholds of >85% overlay accuracy and positive predictive value (PPV) > 30% and negative predictive value NPV > 95% for alerts to move into clinical validation. An ETT was present in 285 of 512 test cases. The AI detected 95% (271/285) of ETTs, 233 (86%) of these with accurate tip localization. The system (correctly) did not generate an ETT overlay in 221/227 CXRs where the tube was absent for an overall overlay accuracy of 89% (454/512). The alert messages indicating that either the ETT was misplaced or not detected had a PPV of 83% (265/320) and NPV of 98% (188/192). The chest X-ray AI met prespecified performance thresholds to move into clinical validation.

Is endotracheal tube displacement during head and neck extension due to ascending movement or tracheal lengthening? An observational ultrasonographic study.

Complications of the endotracheal tube (ETT) displacement during head and neck positional changes are related to not only the tip position but also the cuff pressure against the larynx. Here, we evaluated movement of the ETT cuff relative to laryngeal structures as well as tip displacement from the carina.Sixty-two patients scheduled for thyroidectomy were recruited. The distance from the cricoid cartilage to the upper margin of the cuff (CC) and that from the ETT tip to the carina (TC) were measured using ultrasonography and fiberoptic bronchoscopy, respectively, during flexion and extension. The total tracheal length (TTL) was defined as the combination of CC, TC, and the distance from the upper margin of the cuff to the tip.During flexion, the CC and TC were 1.5 ± 0.6 and 2.9 ± 1.0cm respectively. Seven patients (11.7%) exhibited excessively deep intubation. After adjusting the cuff position under ultrasonography (CC = 0), the tip position was corrected in 96.7%. While the TC increased by 2.1 ± 1.0cm after the positional change in extension, the CC decreased by 0.6 ± 0.7cm because the TTL lengthened (1.4 ± 1.1cm). Four patients (6.7%) exhibited excessive cuff displacement beyond the cricoid cartilage, which could have been corrected under ultrasonography.In conclusion, the ETT cuff displaced toward the larynx in a less degree than the tip did from the carina due to the tracheal lengthening during head and neck extension. Nevertheless, we suggest that ultrasonographic assessment of cuff position may avoid ETT misplacement. Trial registration https://cris.nih.go.kr/ (approval no. KCT0005319); registered on May 14, 2019.

FACTORS ASSOCIATED WITH ENDOTRACHEAL TUBE MALPOSITION AMONG PEDIATRIC PATIENTS WITH HEART DISEASE: A CROSS-SECTIONAL ANALYTICAL STUDY

TOPIC: Respiratory Care TYPE: Original Investigations PURPOSE: Several guidelines and formula for endotracheal tube depth insertion are being studied and used. These suggested formulas in computation for the endotracheal tube (ETT) size and depth are based on age, weight and height of those with normal growth and mostly of the Western population. These may not be applicable for those children with growth impairment in patients with cardiac diseases. Investigation of the incidence of inappropriate ETT size and ETT malposition is important to lessen pulmonary complications in these population. METHODS: This is a cross-sectional analytical study approved by the Institutional Review Board of the Philippine Heart Center. Review of charts of pediatric patients, neonates up to 18 years of age with heart disease, who has undergone endotracheal intubation between April 1, 2017 and December 31, 2019 was done. Age, gender, nutritional status, type of heart disease, setting of intubation, formula in computing for the ETT depth, and complications were all obtained from the charts of the patient. The actual ETT placement was compared with the computed ETT depth to identify which guideline specific formula was used. ETT placement, measured in centimeters, seen in chest radiograph taken in neutral position right after intubation was also obtained from the record of the patients. The chest radiographs were evaluated by a single identified radiologist to prevent inter-reader variation. RESULTS: A total of 99 patients with heart disease who underwent endotracheal intubation were included with age ranging from 4 days to 18 years and mean age of 87.71 months (±14.04). There is male preponderance (60.6%). From the review of the post-intubation chest radiographs, 51.52% endotracheal tubes were in place and 48.48% were misplaced. The presence of malnutrition was not a significant factor (p=0.52). However, from the different types of malnutrition, severe stunting (p=0.021) was a factor in the occurrence of malpositioned ETT. Patients with severe stunting, were 3.23 times more likely to have malpositioned ETT as compared to those with normal growth and to those with stunting. In the multivariate analysis, the use of guideline-specified formula was noted to be a significant factor in decreasing the likelihood of malpositioned ETT. Neonates intubated using the Neonatal Resuscitation Program (NRP) formula were 96.87% less likely to have malpositioned endotracheal tube. Furthermore, the NRP guideline was also utilized in infants up to 2 months old who weighed less than 4 kilograms. For those belonging to older age group, Internal Diameter (ID) estimation and Pediatric Advanced Life Support (PALS) formula were 75.33% and 70.88% less likely to have malpositioned ETT, respectively. Wheezing or bronchospasm was the most common complication followed by atelectasis of the left lung. CONCLUSIONS: There are several guidelines and recommendations in proper endotracheal tube insertion a mediical provider may choose and use; however, important factors and characteristics of the individual patient, such as his or her nutritional status should be taken into consideration. CLINICAL IMPLICATIONS: This important and life-saving emergency procedure should be further studied in the pediatric population with different growth patterns to decrease incidence of malpositoning and further pulmonary complications. DISCLOSURES: No relevant relationships by Karenne Somera, source=Web Response

Accuracy Comparison of Endotracheal Tube (ETT) Placement Using Chula Formula With Manubrium Sternal Joint (MSJ) Formula

Introduction: Intubation mistakes, such as ETT malposition, will result in serious complications. Endobronchial intubation can cause pneumothorax and contralateral lung collapse (atelectasis). On the contrary, superficial ETT could increase the risk of being released easily, leading to desaturation or even cardiac arrest. A shallow ETT position could cause the compression of the vocal cord and laryngeal nerve by ETT's cuff. An optimal position can be reached if the cuff position is 1.5-2.5 cm under the vocal cord and the tip is 3-5 cm above the carina. Several methods of ETT depth measurement based on airway length data can be an alternative, especially during the COVID-19 era, where the use of a stethoscope to check ETT depth is limited. Objectives: To analyze the accuracy of ETT depth placement using Chula and MSJ formula. Methods and Material: We conducted the prospective comparative analytic research on 50 patients who had elective surgery in GBPT operating room at Dr. Soetomo Hospital Surabaya. The research data during the intubation and FOL (Fyber Optic Laryngoscope) from each patient were height, MSJ length, initial ETT length, the distance of carina-ETT tip, the distance of cuff-vocal cord, and final ETT length. Result and Discussion: In the Chula formula group, the average patients' height was 160.60cm ± 9.738 for men and 157.76 cm ± 8.604 for women. The average MSJ length was 20.28 cm. The application of the Chula formula is more accurate because ETT revision was carried out in only 8.0% of the samples, with an average revision is 0.04. On the other hand, the ETT revision with an average of 0.868 on the MSJ formula group was conducted in 84% of the samples. This research also found a linear correlation between increasing ETT depth and body height. Conclusion: Applying the Chula formula to measure the ETT depth for Indonesian (Javanese) people is more appropriate than the MSJ formula.

Comparison of Intubation with Chula Formula Method and Manubrium Sternal Joint (MSJ) Formula against Oxygenation and Sore Throat in General Anaesthesia at Dr. Soetomo General Hospital

Intubation is a way to free the airway during general anesthesia procedures, but some severe complications can arise from this procedure, such as desaturation up to the cardiac arrest and brain damage. Another complication that can arise from ETT insertion is a sore throat. Optimal Endotracheal Tube (ETT) depth is a significant concern because of complications associated with ETT malposition. By using the right formula, the incidence of sore throat and desaturation can be minimized. This study compared the Chula formula's intubation method and the Manubrium sternal Joint (MSJ) formula against oxygenation and sore throat under general anesthesia. This research is a prospective comparative analytical study carried out on 50 people aged ≥ 18- ≤ 65 years, with the American Society of Anesthesiology (ASA) I-III, Malampari score I-II and conducted in Dr. Soetomo General Hospital Surabaya's surgical room from September-October 2020. Subjects were divided into two treatment groups: those with ETT depth measurements using the formula Chula and groups with Manubrium Sternal Joint (MSJ). Assessment of ETT tip distance to the carina using a Fiberoptic Laryngoscope (FOL), while oxygenation measured by pulse oxymetry and sore throat using a questionnaire. This study showed optimal oxygenation and minimal sore throat incidence in the Chula formula was better than the MSJ technique. Statistical analysis used the Kolmogorov-Smirnov test. The analysis results showed statistically significant differences (p<0.05). This research concludes that the use of the Chula formula results in optimal oxygenation and minimal sore throat.

'Lip-to-Tip' study: comparison of three methods to determine optimal insertion length of endotracheal tube in neonates.

The aim of this prospective observational study was to compare the incidence of endotracheal tube (ETT) malposition using weight-based (Tochen), gestation-based (Kempley), and nasotragal length (NTL) methods in deceased neonates and fresh stillbirths. We enrolled deceased neonates and fresh stillbirths within 2 ± 1 h of death or delivery, respectively; without hydrops, tracheostomy or major congenital anomalies affecting face, neck, or thorax. Each enrolled subject was intubated orotracheally, with lip-to-tip distance determined by three methods in random succession. Chest X-ray was acquired after each insertion. The primary outcome was proportion of malpositioned ETTs on chest X-ray (defined as ETT tip not lying between upper border of T1 and lower border of T2 vertebrae), assessed by two experts masked to the methods used. The proportion of malpositioned tubes was not significantly different with any of the three methods: (weight 27/50 (54%), gestation 35/50 (70%), and NTL 35/50 (70%), p value 0.055). The malpositioned tubes were too far in (87/150; 58%) than too far out (10/150; 6.7%).Conclusions: None of the currently recommended methods accurately predicts optimal ETT length in neonates. There is an urgent need for newer bedside modalities for estimating ETT position in neonates. What is known? • NRP guidelines recommend gestation-based and nasotragal length (NTL) methods to estimate initial ETT depth in neonates. Weight-based (Tochen) method is still widely used in neonatal units for ETT depth estimation. Evidence till date has not proven superiority of one method over the other. What is new? • All three methods for ETT depth estimation (Tochen, gestation-based, and NTL) resulted in high rates of ETT malposition in neonates. Formulae, devised from this study based on linear regression models, did not perform well for estimation of optimal ETT position.

Comparison of Intubation with Chula Formula Method and Manubrium Sternal Joint (MSJ) Formula against Oxygenation and Sore Throat in General Anaesthesia at Dr. Soetomo General Hospital

Intubation is a way to free the airway during general anesthesia procedures, but some severe complications can arise from this procedure, such as desaturation up to the cardiac arrest and brain damage. Another complication that can arise from ETT insertion is a sore throat. Optimal Endotracheal Tube (ETT) depth is a significant concern because of complications associated with ETT malposition. By using the right formula, the incidence of sore throat and desaturation can be minimized. This study compared the Chula formula's intubation method and the Manubrium sternal Joint (MSJ) formula against oxygenation and sore throat under general anesthesia. This research is a prospective comparative analytical study carried out on 50 people aged ≥ 18- ≤ 65 years, with the American Society of Anesthesiology (ASA) I-III, Malampari score I-II and conducted in Dr. Soetomo General Hospital Surabaya's surgical room from September-October 2020. Subjects were divided into two treatment groups: those with ETT depth measurements using the formula Chula and groups with Manubrium Sternal Joint (MSJ). Assessment of ETT tip distance to the carina using a Fiberoptic Laryngoscope (FOL), while oxygenation measured by pulse oxymetry and sore throat using a questionnaire. This study showed optimal oxygenation and minimal sore throat incidence in the Chula formula was better than the MSJ technique. Statistical analysis used the Kolmogorov-Smirnov test. The analysis results showed statistically significant differences (p<0.05). This research concludes that the use of the Chula formula results in optimal oxygenation and minimal sore throat.

A prospective observational trial evaluating factors predictive of accurate endotracheal tube positioning in neonates and small infants.

There is a high incidence of endotracheal tube malposition in neonates and small infants. Yet, verification of accurate endotracheal tube location via radiographic imaging involves radiation exposure. This study aimed to identify demographic and clinical parameters associated with accurate endotracheal tube positioning. We conducted a prospective single-center study with term and preterm neonates and small infants between January 2018 and November 2019. We investigated correlations between ten variables and accurate endotracheal tube position. One hundred and sixty eight nasal intubations in 139 patients (weight 390-5000g) were analyzed. An accurate tube position was confirmed by radiographic imaging in 71.4% of the intubations. The endotracheal tube was high in 8.3% and low in 20.2% of the cases. Male gender was the only variable that significantly correlated with an accurate endotracheal tube position (OR 2.5; 95% CI: 1.3, 5.0; P=.010). So far, no parameter has proven to be able to predict accurate endotracheal tube position in neonates reliably. These findings emphasize the indispensability of postintubation imaging in neonates and small infants.

Pronation Technique in ARDS Patients

In severe acute respiratory distress syndrome (ARDS), characterized by the ratio of arterial partial pressure of oxygen over fraction of inspired oxygen (P/F) less than 150 mm Hg, pronation cycles are the only intervention that showed improved survival, in combination with protective ventilation. The physiological advantages of performing pronation cycles, such as the improvement of oxygenation, better tidal volume distribution with increased involvement of dorsal regions, and easier drainage of secretions, overcome the possible complications, that is, endotracheal tube occlusion or misplacement, pressure ulcers, and brachial plexus injury. However, the incidence of complications is dramatically lower in intensive care units with expertise, adopting prone positioning in daily practice.&#x0D; In this video we are proposing step by step an easy and ergonomic technique to perform pronation maneuvers in patients with severe ARDS. Recent literature suggests that a high percentage of these patients are treated without undergoing pronation cycles.&#x0D; The main purpose of this video is to help increase the number of intensive care units worldwide commonly performing pronation cycles in patients that have indications to be pronated, in order to decrease healthcare burden and costs directly caused by ARDS.&#x0D; Proper intensive care unit staff training is fundamental in minimizing the risks associated with the maneuver for both patients and operators; and diffusion of a safe technique encouraging the operators is the second main purpose of this video.&#x0D; &#x0D; (This video was recorded before the COVID-19 outbreak)

Determination of optimal endotracheal tube tip depth from the gum in neonates by X-ray and ultrasound

Background/objective: Proper placement of endotracheal tube (ETT) in the midtrachea is essential. Initial depth of placement of oral ETT from the lips is commonly estimated based on weight (“7-8-9 rule”), gestational age, or nasal-tragus distance. However, these measurements can be altered by superficial factors and the mobility of the lips relative to the airway, so the upper alveolar ridge (gum) may provide a superior landmark. Also, confirmation of ETT tip position by point of care ultrasound (POC-US) is noninvasive and may enable localization of the ETT tip in real time. The objective of this study is to define optimal initial ETT depth from the gum in infants relative to weight, and to compare the efficacy of POC-US with standard chest X-ray (CXR) for confirming ETT tip position.Methods: Neonates requiring oral intubation were enrolled. At the time of CXR that were obtained for clinical indications, the position of the ETT at both the lip and gum were recorded. “Optimal” ETT placement in midtrachea (from lip and gum) was calculated based on the observed measurements and the distance of the ETT tip from the carina on CXR. Linear regression was used to model ideal placement of ETT, as a function of weight. POC-US was performed using a 10 MHz cardiac probe and high parasternal view. Distance from the ETT bevel to the superior aspect of the right pulmonary artery, which is at the level of carina, was measured using electronic calipers.Results: Infants were recruited at a median age of 3 days (n = 75), weight 1300 g, and corrected gestational age 31.6 ± 5.8 weeks. The regression equation for optimal placement from the gum (in cm) was 5.21 + 1.03 × weight (kg). Using estimates of 5 or 5.5 cm + weight (kg) to the gum yielded accuracy similar or superior to the 7-8-9 rule to the lip. Most of the variability in ideal placement of ETT tip from the gum was determined by weight (R2 = 0.83). The difference between optimal placement using lip and gum was 0.51 ± 0.24 cm. ETT location by POC-US (n = 40) was in substantial agreement with CXR (intraclass correlation coefficient 0.95, 95% CI: 0.92, 0.98).Conclusions: Marking oral ETT placement to the gum is feasible, with optimal depth of about 5.2 cm + weight (kg), across all weight categories. POC-US can be used for rapid confirmation of continued ideal ETT tip location, with accuracy similar to CXR. Further studies will be needed to determine whether marking ETT depth to the gum or using POC-US achieves the goal of decreased complications of ETT misplacement or displacement.

Conservative management of esophageal perforation caused by misplacement of endotracheal tube.

Conservative management of esophageal perforation caused by misplacement of endotracheal tube.

Decreasing Time from Decision to Intubation in Premedicated Neonates: A Quality Improvement Initiative.

Introduction:Endotracheal intubation carries the risk of discomfort, decompensation, oral trauma, and endotracheal tube malposition. Treatment with premedications reduces complications, increases overall intubation safety, improves pain control, and improves first-pass success. However, time is frequently a barrier to administration. We aimed to decrease the decision-to-intubation time interval from a baseline of 40 minutes to less than 35 minutes over 6 months.Methods:We used the Model for Improvement with multiple plan–do–study–act cycles to reduce the time from decision to successful intubation in nonemergent neonatal intubations. Key drivers were timely administration of medications, availability of skilled personnel and equipment, and efficient use of time.Results:During this project, time from the decision to successful intubation decreased from a historical mean of 40 minutes to a new baseline of 27 minutes. This change represents a 33% decrease, with 80% of intubations occurring within 35 minutes. During this time, success rates remained stable, and medication errors and side effects did not increase.Conclusions:Standard processes to prepare and administer premedications decreased the time from decision to intubation without significant adverse effects, allowing the benefit of premedication administration in a safe and timely manner in nonemergent neonatal intubations.

Surveying the Literature

Surveying the Literature

A multi-center evaluation of a disposable catheter to aid in correct positioning of the endotracheal tube after intubation in critically ill patients

PurposeTo demonstrate that use of a minimally invasive catheter reduces endotracheal tube (ETT) malposition rate after intubation. Materials and methodsThis study is a multi-center, prospective observational cohort of intubated patients in the medical intensive care unit. The catheter was inserted into the ETT immediately after intubation. The ETT was adjusted accordingly based on qualitative color markers on the catheter. A confirmatory chest radiograph was obtained to determine the ETT position. Malposition of the ETT was defined by the distal ETT not being within 2–5 cm above the carina. ResultsSixty-nine patients were enrolled, age 56.2 ± 19.5 years, body mass index 31.0 ± 13.8 kg/m2. The catheter prompted repositioning of the ETT in 39 (56.5%) patients. Using the catheter, the rate of malposition decreased to 7.2%, with the distal ETT position at 3.7 ± 1.2 cm above the carina. Without the catheter, the ETT malposition rate would have been 39.1%. The time for catheter use and chest radiograph completion at our institutions was 1.7 ± 1.5 and 44.4 ± 36.4 min, respectively. ConclusionsWith use of an ETT positioning catheter after intubation, the ETT malposition rate was reduced by 82%. This catheter-based system was safe, and its use may perhaps decrease the need for the post-intubation chest radiograph.

Transcutaneous Recording During Intraoperative Neuromonitoring in Thyroid Surgery.

Recurrent laryngeal nerve (RLN) palsy remains a major source of morbidity after thyroid surgeries. Intraoperative neural monitoring (IONM) has gained increasing acceptance as an adjunct to standard practice of visual RLN identification. Endotracheal tube (ETT) surface recording electrodes systems are now widely used for IONM; however, a malpositioned ETT can cause false IONM results and requires time-consuming intraoperative verification of the ETT position and readjustment by the anesthesiologist. The aim of this experimental study was to evaluate the feasibility of the transcutaneous approach for recording evoked laryngeal electromyography (EMG) signals during IONM. A porcine model with well-established applicability in IONM research was used. Twelve piglets (24 nerve sides) were enrolled. Electrically evoked EMGs were recorded from surface electrodes on the ETT and from the adhesive pre-gelled surface electrodes on the anterior neck skin. The evoked EMG waveforms were measured and analyzed. The real-time signal stability of the electrodes during tracheal displacement and their accuracy in reflecting adverse EMG changes during RLN stress were evaluated during continuous IONM performed with automatic periodic vagus nerve (VN) stimulation. In all nerves, both the ETT and neck adhesive skin electrodes successfully recorded typical evoked laryngeal EMG waveforms from the RLNs and VNs under stimulation with 1 mA. The transcutaneous electrodes recorded mean EMG amplitudes of 264 μV (±79) under RLN stimulation and 202 μV (±55) under VN stimulation. The electrodes recorded mean EMG latencies of 2.98 ms (±0.20) under RLN stimulation, 4.51 ms (±0.50) under right VN stimulation, and 8.13 ms (±0.94) under left VN stimulation, respectively. When tracheal displacement was experimentally induced, the EMG signals obtained by ETT electrodes varied significantly, but those obtained by transcutaneous electrodes did not. When RLN traction stress was experimentally induced, both ETT and transcutaneous electrodes recorded the same pattern of progressively degrading EMG amplitude with gradual recovery after release of traction. This study confirms the feasibility of transcutaneous recording of evoked laryngeal EMG during IONM. Although this study confirms the stability and accuracy of the transcutaneous approach, it also revealed the need for new electrode designs to improve EMG amplitudes before practical clinical application of this approach.

Wilderness First Responder: Are Skills Soon Forgotten?

Wilderness first responders are trained to provide competent medical care in wilderness settings or until evacuation for more advanced treatment can be obtained. In light of the isolated environments in which they are called upon to respond to illnesses and injuries, their ability to effectively apply their training is crucial. Despite the responsibility assigned to them, there is an absence of research assessing the skill and knowledge retention of wilderness first responders, creating a gap in understanding whether a deficit in their ability to perform exists between certifications. Without such research, it is important to review knowledge and skill retention in related responder groups. The literature over the past 4 decades documents the loss over time of skills and knowledge across an array of trained responders, both professional and laypeople. Although the findings reviewed suggest that WFRs will exhibit a similar pattern of increasing skill loss beginning shortly after certification and a slower, but concurrent, decrease in knowledge, research is needed to document or refute this assumption.